New Zealand–based trained massage therapists (men and women) from established MT practices with repeat clients constituted the target group for the larger study and the concurrent therapist survey. The sampling frame was the membership list of MNZ (both membership categories—CMT and RMT—were included). Members of MNZ were included if they had a massage volume of at least 5 massages in a typical week, had provided at least 5 clients with a minimum of 2 sessions in the last 3 months, were 16 years of age or older, and had the motivation to see the study through to its completion. Therapists who were not currently practicing or were not comfortable with written English were excluded. In addition, massage therapists trained in other health professions and providing massage as an adjunct to physiotherapy, osteopathy, chiropractic, or nursing, and those working in a massage parlor were excluded. These inclusion/exclusion criteria were related to the objectives of the parent study (Smith JM. Massage therapy services for health needs: drivers, utilisation, culture of care, and practice patterns of massage therapy in NZ. PhD thesis; University of Otago, Dunedin, NZ; 2009).

A questionnaire (36 items, open and closed responses, 6 single-sided pages) was designed to collect information related to therapist characteristics; practice modes and settings; and MT techniques, assessment, and reassessment practices. A list of topic areas were initially compiled from the research objectives; the literature (Osborn CE. Complementary and alternative medicine and the treatment of rheumatic diseases: focusing on aromatherapy. PhD thesis; Coventry University, Coventry, UK; 2001; Quinn F. Complementary and alternative medicine in the treatment of low back pain, with a focus on reflexology. PhD thesis; University of Ulster, Belfast, UK; 2006)^{(7,8,20,25,30–35)}; consultation with Māori (NZ indigenous peoples); collegial discussions; and from the words and themes derived from a telephone focus-group study of massage clients^(36,37) and massage therapists (Smith JM. Massage therapy services for health needs: drivers, utilisation, culture of care, and practice patterns of massage therapy in NZ. PhD thesis; University of Otago, Dunedin, NZ; 2009). The questionnaire was further developed using an expert panel (researchers, massage therapists, and methodologists) and was subsequently pilot tested. The University of Otago Human Ethics Committee approved the final questionnaire.

Of the approximately 250 massage therapists listed as members of MNZ, 92 who met the inclusion criteria volunteered for the parent study. They were recruited using four approaches (e-mail, the “members only” forum page of the MNZ website, the MNZ newsletter, and their publicly listed “find a therapist” web page) and invited to participate. The self-report postal questionnaire was distributed during May – September 2008; massage therapists were asked to complete the questionnaire at their leisure and return it to the researcher within 7 days in the addressed freepost envelope. On receipt, completed questionnaires were manually coded, and the codes were entered into data files using the Statistical Package for the Social Sciences software (version 15: SPSS, Chicago, IL, USA). Results were analyzed using descriptive statistics (for example, means, medians, frequency counts).

From among 92 questionnaires distributed, 66 responses were received (response rate of 71.7%; 7 withdrew, 19 failed to respond). Of the 18 designated NZ regions, 12 were represented. Respondents came from North and South Island rural and urban regions, and major city areas were well represented; only the regions of Taranaki, Wanganui, Manawatu, Wairarapa, Marlborough, and West Coast were not represented.

Most participants were female (83.3%), NZ European (75.8%), and 28 – 64 years of age [mean: 45.8 ± 8.7 years (standard deviation)]. The number of years of MT practice ranged from 0.5 years to 34 years (mean: 9.0 ± 6.0 years; median: 7.0 years). The therapists’ MT qualifications ranged from a certificate to a baccalaureate degree, with a post–high school diploma (from a polytechnic or other tertiary training provider) being the most commonly reported qualification (89.4%). Qualifications were primarily obtained in New Zealand (93.9%). About half (51.5%) had received their highest MT qualification in the preceding 5 years. Participants also commonly held other non-massage related qualifications (65.6%): 9 (13.6%) held a current annual practicing certificate (or professional license) from another health profession (3 were CAM-related, 2 were nursing-related). In addition to being members of MNZ, 11 respondents (16.7%) were also members of other professional associations.

Slightly more than half the respondents (57.6%) self-reported practicing “full time” as massage therapists, with the practice of MT being the sole source of employment for 46 therapists (69.7%). Therapists commonly practiced MT for 46 – 50 weeks in a “typical year” (68.3%), and nearly all (93.7%) practiced massage for more than 40 weeks in the year. About two thirds of therapists (65.7%) reported typically handling between 10 and 29 client visits per week (Figure 1) and a median of 16 – 20 hours of direct client care per week (Figure 2).

Practice settings varied. They included “solo practice” (57.6%) and group practice “within a multidisciplinary group” (31.8%) and “with a group of massage therapists” (18.2%); however, about half the therapists (54.5%) also practiced in more than one practice setting. Multidisciplinary group practices included a range of the following professions or professionals: osteopaths, beauticians, naturopaths, general practitioners, chiropractors, acupuncturists, counselors, social service providers, nurses, sports trainers, and physiotherapists. A range of practice locations and treatment durations were also identified (Table 1). The most frequent client fee per treatment was NZ$60 per hour in a clinic and NZ$1 per minute at a sports event or in the workplace. Variability in treatment durations within and between treatment locations were reported.

Most therapists (89.2%) received referrals from the client’s general practitioner or other health professionals. Common sources of referral were physiotherapists (67.2%), general practitioners (60.3%), chiropractors (34.5%), and osteopaths (25.9%). Less common sources of referral included acupuncturists (10.3%), podiatrists (8.6%), personal trainers (5.2%), hospital nurses (3.4%), naturopaths (3.4%), sports medicine specialists (3.4%), the Accident Compensation Corporation (1.7%), counselors (1.7%), dentists (1.7%), homeopaths (1.7%), midwives (1.7%), occupational health nurses (1.7%), occupational therapists (1.7%), orthopedic surgeons (1.7%), other massage therapists (1.7%), Pilates instructors (1.7%), the Primary Health Organisation mental health initiative (1.7%), psychologists (1.7%), and psychotherapists (1.7%). Similarly, therapists commonly referred their clients to a large number of health professionals (Table 2). General practitioners (69.7%) were the professionals most commonly referred to, followed by osteopaths and physiotherapists.

A wide range of massage styles were offered (Table 3), and therapists reported treating a wide spectrum of symptoms (Table 4), including musculoskeletal, neurological, and psychological. Slightly more than one third of massage therapists (n = 24, 36.4%) also practiced other forms of complementary therapy, such as acupressure, aromatherapy, Reiki, light therapy, herbal remedies and supplements, Bowen therapy, craniosacral therapy, lifestyle coaching, homeopathy, and reflexology. Of those 24 therapists, 21 reported combining CAM with their massage consultations. The most common client issues and conditions reported (Table 5) were musculoskeletal problems (98%), especially back, neck/shoulder, and headache problems, and relaxation and stress reduction (95%). The most common style of massage offered was “therapeutic massage,” followed by “relaxation massage,” “sports massage,” and “trigger-point therapy” respectively. Almost all therapists treated musculoskeletal symptoms—for example, “muscle pain,” “stiffness,” “tension,” and “reduced mobility and strength.” However, fatigue, nervous system symptoms (for example, “numbness,” “altered sensation”), wellness symptoms (for example, “sleep disturbance,” “sense of heaviness,” “disconnection with body”), and psychological and mental health symptoms (for example, “sense of being out of balance,” “anxiety or depression”) had also been seen by more than 24% of the massage therapists at least once in the last 12 months.

Most massage therapists (98.5%) undertook client assessment for their “typical client,” with most commonly using the methods of “subjective assessment/history taking” (98.5%), “tissue assessment using palpation” (90.9%), “postural assessment” (83.3%), and “active range of motion” measures (78.8%). “Passive range of motion” (69.7%), “pain measures” (68.2%), and “resisted tests” (50%) were used by 50% or more of the therapists. Tests considered more “specialized”—that is, “muscle length tests” (43.9%), “orthopedic tests” (22.7%), “neurological tests” (19.7%)—were less commonly used.

More than 95% of the therapists reported typically providing self-care recommendations (Table 6). “Increasing water intake” (94%), “stretches” (88%), “active movement” (79%), “body awareness” (76%), and “hot/cold therapy” (76%) were the most common recommendations; resisted exercise (46%) was less commonly recommended. Treatment effects or outcomes typically monitored for evaluating treatment effectiveness (Table 7) were client report (97%), range of movement (90.1%), pain level (90.1%), and client satisfaction (89.4%).

A small number of key professional issues were also surveyed. Insurance cover for massage therapists is voluntary in New Zealand, and just over 50% of therapists (52.3%) had professional indemnity, public liability, or similar insurance cover as a massage therapist for their practice. A quarter of the therapists surveyed (25.8%) had experienced an occupational health issue or injury from delivering MT; injuries were to the “hand, wrist, thumb, forearm” (58.8%), “shoulder, arm” (29.4%), “neck, upper back” (17.6%), “back” (17.6%), “knees” (5.9%), and “burnout” (5.9%).

The results reported here are congruent with those in a previous study⁽²⁰⁾ and from New Zealand census data⁽²⁹⁾, in that most therapists are female (83%), NZ European (76%), and a mean of 45.8 years of age; 6% were Māori. However, the median years in practice (7.0 years) was higher than that found in a US study conducted in the states of Washington and Connecticut (median: 4.0 – 5.0 years)⁽²⁰⁾, reflecting the large range in number of years in practice (0.5 – 34 years).

Most therapists had completed their first massage qualification more than 6 – 10 years earlier, but more than half of respondents had received their “highest massage qualification” in the preceding 1 – 5 years, indicating some recency or up-skilling of qualifications. A massage diploma from a NZ massage education provider was the most common qualification, but massage baccalaureate training also featured among respondents. Other non-massage-related qualifications (for example, nursing) were common, perhaps because of the mean age of the therapists, previous life experience, a secondary or subsequent career, and compatibility with other hands-on caring professions.

A typical massage diploma qualification in NZ ranges from 1200 hours to 2400 hours in duration of training, with baccalaureate training in MT being 3600 hours. Research literacy is a key component of New Zealand–based baccalaureates⁽³⁸⁾, but it is not a key component of New Zealand–based diplomas. As such, the ability of massage practitioners (predominantly holding diploma qualifications) to individually engage with the rapidly expanding knowledge base for MT⁽³⁹⁾ may be hindered. Low levels of research literacy and capability were also identified in a survey of massage therapists in Alberta, Canada⁽⁴⁰⁾. This pattern of qualifications and skills may change as younger students perceive MT to be a viable career choice and as graduates from the two New Zealand–based baccalaureate degree programs in MT enter the MT workforce, MNZ, and postgraduate education.

Again, like the distribution of modes of practice reported by Cherkin et al.⁽²⁰⁾, “solo,” but also “massage group practices” and “multidisciplinary practices,” were common among most respondents; yet despite such similarities, fewer MNZ therapists practiced alone (58% vs. 71% – 73%) than did Washington and Connecticut therapists, and slightly more practiced in multidisciplinary settings.

Multidisciplinary practices in NZ involved a wide range of professionals. However, multidisciplinary settings typically involved working with other CAM providers, which accorded with results from the US study⁽²⁰⁾; integration with conventional medical practices was rare. Within the NZ context, the concept of integrated care appears to be less well recognized and developed, as evidenced by a paucity of literature and minimal mention in health policy documents (the New Zealand Health Strategy, for instance). Against this background, multidisciplinary practice may simply reflect a need for cost-sharing, resulting from the number of hours of direct client care per week or the part-time or multi-setting nature of massage practice. The drivers for multidisciplinary practice (for example, cost-sharing or integrative care) therefore warrant further, more detailed, investigation to determine the reasons for and benefits of integration into multidisciplinary settings, and to provide insight into the evolvement of integrative care in New Zealand.

A range of practice settings was also evident. Dedicated non-home-based clinical facilities were most common (as they are with other more established musculoskeletal practitioners—for example, chiropractors, physiotherapists), but use of home-based clinics was also reported, perhaps again reflecting the part-time nature of MT. Similarly, massage was practiced in the sports, workplace, hospice, spa, hospitality, and mobile settings, suggesting an increase in employment opportunities within those settings, paralleling similar developments in the United States^(4,21). The 30% of US therapists practicing at a sports event contrasted notably with the 4% reported in the NZ Department of Labour survey⁽²⁹⁾; the foregoing differences may be a result of the sample population or may indicate a change in trend.

One notable difference between New Zealand and the United States was an apparent lack of MT practice in the NZ hospital setting. This difference may be in part a result of a contemporary practice of nurses and physiotherapists in NZ hospitals incorporating some MT care, or it may reflect a slow uptake of integrative care in New Zealand. It may also result from differences in public and private hospital care between the two countries, or a lack of a formal licensing or regulatory system⁽⁴¹⁾ for the practice of MT in New Zealand. Also different was the pattern of spa work: In 2008 in the United States, 29% of therapists worked in a spa⁽²¹⁾; only 6% of MNZ therapists worked in the spa/beauty therapy setting. Such differences may be attributable to the sample surveyed (rather than being representative of the wider population of massage therapists), or they may indicate that massage in the spa setting is less well developed in New Zealand at this time.

The commonly used massage styles and most frequent issues or conditions seen by massage therapists were again similar to those reported in US-based studies^(8,42), suggesting some cross-national congruency both in massage styles and massage client issues or conditions. Although therapists in the present study were not specifically asked the number of styles they typically used for a single client, a range of 26 different massage or bodywork styles were collectively identified by survey respondents. Within the reported massage styles offered, there was evidence to support all four principal goals of treatment—relaxation massage, clinical massage, movement re-education, and energy work—identified by Sherman and colleagues⁽⁶⁾. Approximately 14% of therapists also held annual practicing certificates (licenses) for other CAM modalities or for nursing: 36% practiced other forms of complementary therapies, with 32% combining CAM with their massage consultations. Clearly then, therapists may blend a number of different health philosophies and practices (for example, assessment, clinical reasoning, styles of massage) into their practice of MT, and the patterns of practice reported may therefore not reflect purely those of MT.

Assessment techniques and self-care recommendations given to clients (most commonly, increased water intake, stretches, and active movement) were also similar to those reported by Sherman et al.⁽³⁴⁾; however, further research investigating the specific advice dispensed is needed, given that many clients self-refer, receive MT as a standalone therapy, experience variability in the duration of treatments, and value the education and information sharing^(36,37) provided by therapists. Further research into the “whens” and “whys” that therapists are using as assessment methods is required. In addition, investigation is needed regarding the suitability of assessment methods, measures of effectiveness, and MT training in relation to the symptoms and conditions being treated by therapists. Reinforcing that view is the finding that, although most therapists monitored treatment effects or outcomes, commonly used measures of treatment effectiveness were “client reports ‘feels better’,” “pain levels,” and client satisfaction. The authors suggest that massage therapists as health care service providers, have to demonstrate effective measurement of their interventions, not only as a prerequisite to providing appropriate interventions to their clients, but also for demonstration of quality services, accountability, and continual performance improvement. That need is even more pressing if MT service providers want to seek external funder reimbursement for services; current effectiveness measures may be inadequate.

The present findings indicated that MT was practiced by therapists as either a full- or part-time occupation, which is similar to findings reported by Cherkin and colleagues⁽²⁰⁾ that MT was commonly practiced for 46 – 50 weeks per annum. However, the terms “full-time” and “part-time” were not defined and responses to subsequent qualifying questions (self-reported measures of “hours of direct client care” and “number of clients visits per week”) suggest that the practice of MT may not equate to a 40-hour work week for a large number of respondents. The physical nature of MT, the availability of clients, and a desire for part-time work or access to client-friendly appointment times may limit the hours of work per week. The move by some therapists to integrate other CAM therapies that are less physically demanding (for example, aromatherapy, Reiki, light therapy, herbal remedies and supplements, craniosacral therapy, lifestyle coaching, homeopathy) may provide an opportunity to increase hours per week associated with the additional skills, to create more potential diversity in their client market, and to lessen physical demands. Future research into the workload of massage therapists needs to define “full-time” and “part-time” and to account for direct client care and various non-client-care aspects of the job.

The most frequent client fee per treatment was NZ$60 per hour in a clinic. Massage sessions are commonly privately paid and medical insurance reimbursement or other third-party payments (for example, from an employer or government) are negligible (Smith JM. Massage therapy services for health needs: drivers, utilisation, culture of care, and practice patterns of massage therapy in NZ. PhD thesis; University of Otago, Dunedin, NZ; 2009). These factors of cost and payment source provide an important contextual element to the massage user demographic of a higher-than-average household income (Smith JM. Massage therapy services for health needs: drivers, utilisation, culture of care, and practice patterns of massage therapy in NZ. PhD thesis; University of Otago, Dunedin, NZ; 2009) and may also partly explain the proactive and health conscious approach of massage users⁽³⁷⁾.

Notably, the commonly used massage styles (for example, therapeutic massage, neuromuscular therapy) are more physically demanding than other styles of MT, reinforcing the physical nature of the job. It is therefore not surprising to see that 26% of therapists had experienced an occupational health issue or injury arising from delivering MT—and in the regions reported by Buck and colleagues⁽⁴³⁾ as being dominant in MT: that is, back and upper extremities. It was not the aim of the current survey to fully investigate therapist injuries resulting from the job, and questions relating to self-care and maintenance, and proper massage therapist posture were therefore not asked. However, the present survey does indicate a likelihood of occupational injury in massage therapists (for example, musculoskeletal pain and discomfort) associated with the practice of MT. Despite injury rates being much lower than those reported by Canadian massage therapists⁽⁴⁴⁾ and physiotherapists⁽⁴⁵⁾, this area needs monitoring for the sustainability of the profession and the health of the massage professional.

Of respondents to the current survey, 60% reported receiving referrals from general practitioners (GPs), suggesting that, although massage therapists cannot bill the public health system for MT services, MT could be seen as being part of the wider health system in New Zealand. Referrals were also commonly received from a broad range of CAM and other conventional health care providers, indicating a wide and active referral network. In addition, massage therapists referred to other massage therapists; however, it is not known whether those referrals reflect unavailability of the therapist, inability of the therapist to treat the condition (that is, because of a lack of expertise or skills), or client relocation. Given that MT use in New Zealand is self-funded (Smith JM. Massage therapy services for health needs: drivers, utilisation, culture of care, and practice patterns of massage therapy in NZ. PhD thesis; University of Otago, Dunedin, NZ; 2009), it would be useful to explore the networking strategies used by massage therapists and the extent of between-provider communication sharing about client management. In addition, further exploration of the reasons for referral by massage therapists is warranted given the range of symptoms with which clients may present, the limited assessment and outcome measurement practices, and the level of training of the therapists.

In US integrative health care clinics, MT is commonly offered as part of the CAM package of therapies⁽⁴⁶⁾. Integrative medicine, with its focus on “health and healing ... [viewing] patients as whole people with minds and spirits as well as bodies”⁽⁴⁷⁾ (p. 119) is congruent with the culture of care of MT practice in New Zealand⁽³⁶⁾. Given the position of integrative medicine in the United States and the potential future role of GPs in informed referral to CAM⁽⁴⁸⁾, the referral patterns described in the present work suggest that new opportunities within integrative care also potentially exist for the NZ massage profession.

The results reported here are based on self-reports of practice by therapists rather than on analyses of client or visit records, and despite obtaining access to trained MNZ-registered massage therapists, it is not known whether the results are representative of all MNZ members or of other massage therapists within New Zealand. More massage therapists in New Zealand are not members of MNZ than are members, and their practice may be different. However, given that a number of trained massage therapists in NZ (who are not MNZ members) would have training credentials similar to the credentials of those surveyed, practice patterns may also be similar.

Care must also be taken when interpreting the descriptive statistics, because the margin of error associated with the data is a larger than might be desirable. Nevertheless, this first survey of MNZ massage therapists provides a useful insight into characteristics of MT practice by this group of massage professionals. Although the numbers surveyed are small (n = 66), national representation was strong, and the response rate of 71.7% was high, reflecting the practice pattern of 26% of the current target population. Only 9% of MNZ therapists surveyed were certificate-trained and therefore qualified at the CMT level to provide relaxation massage. However, relaxation massage was commonly practiced by RMTs (diploma-trained), and so the findings may reflect the practice of both relaxation and therapeutic massage, but from the educational and experience base of a diploma-trained therapeutic (remedial) massage therapist.